Subcostal and intercostal retractions

You are called to the delivery room at 2:00 a.m. for a laboring gravida 1 para 0 mother at 28 weeks gestation. The mother had good an-
prenatal care and had a normal integrated prenatal screening (IPS), normal 20-week ultrasound, and protective serology, including rubella immune, human immunodeficiency virus (HIV) negative, venereal disease research laboratory (VDRL) negative, and hepatitis negative. Group B Streptococcus (GBS) status is unknown as the woman had not yet had swabs done. Social history was negative for tobacco, alcohol, or recreational drug use during the pregnancy. She has gestational diabetes mellitus, which was reasonably controlled by diet and exercise

You arrive at the delivery room moments before the baby is born and prepare equipment for a potential resuscitation, which includes oxygen, a bag and mask, suction, towels to dry, and intubation equipment. At birth, the newborn cries spontaneously. She is placed on the warmer to be dried and stimulated; her heart rate is 120 beats per minute and her respiratory rate is 60 breaths per minute. The infant grunts intermittently. At 4 minutes of age, the newborn has both subcostal and intercostal retractions, nasal flaring, and continuous grunting. Her respiratory rate is now 82 breaths per minute and her heart rate is 190 beats per minute. Oxygen saturation by pulse oximetry is 84% with blow-by oxygen. You begin providing CPAP at 6 cm H2O by mask with a t-piece resuscitator. A systolic murmur gr 2/6 is auscultated loudest at the left upper sternal border (LUSB). The infant is transferred to the NICU where she continues to receive nasal CPAP at 6 cm H2O and a FiO2 of 0.45. The chest X-ray shows a diffuse ground-glass appearance with air bronchograms. An arterial umbilical catheter (UAC) is inserted. Arterial blood gas reveals the following: pH 7.23, CO2 60, PaO2 40, HCO3 27, BE +1, and lactate 4.8.
Blood work shows white blood cell count 20.3, neutrophils 12.3, no left shift, hemoglobin 16.5, platelets 260.


1. What is the first line of therapy for this premature infant considering her presentation?
2. What are the chemical components that make up surfactants?
3. How does surfactant work in the lung?